THE MULTIPLE SCLEROSIS SURVEY


Please fill out this Survey

Note: If you are filling out the survey for someone else please answer all questions as if you were that person.

Name(Optional): (Do not hit return)

1. Year of your birth:

2. Sex?

Female
Male

3 Do you have MS ? (Please complete the survey even if you don't.)

Yes
No
4 Does anyone else in your family have MS ?

No
Brother
Sister
Mother
Father
Other (specify): (Do not hit return)

If you don't have MS skip to question 7
5. How old were you when your symptoms began? : (Do not hit return)

6. What type of MS do you have?

Chronic Progressive
Relapsing Remitting
Benign
Don't know

7. Your race ( check as many as apply)

African American
American Indian
Asian
Caucasian
Hispanic
Oriental
Other(specify): (Do not hit return)

Your Mother's nationality: (Do not hit return)

Your Father's nationality: (Do not hit return)

IF you don't have MS skip to question 10
9. Please indicate the extent of your disability

None- Still functioning normally
Mild- Some difficulty walking
Restricted-Require cane or walker to walk
Severe-Confined to wheelchair or bed
Blind

10)If you have MS confine your answers to the following questions to the time before MS started. IF you don't have MS, answer based on your lifelong habits.

Diet

Please indicate how many times per week you consume the following. (If you changed your diet after you were diagnosed confine you answers to the time before you were diagnosed)

Red meat such as beef, pork, lamb: (Do not hit return)

Cheese (slices per week):

Butter(restraunt size square=1):

Ice cream:

Whole milk (glasses per week):

2% milk (glasses per week):

Eggs (number per week):

Hamburgers or cheeseburgers:

Fish sandwich:

Fried chicken (times per week):

Tacos, burritos, etc:

Pizza (slices per week):

Alcohol (drinks per week):

Chocolate ( one bar =1):

Coffee ( cups per week):

Cigarettes (number per week):

Pop (cans per week):

Bread (slices, bagels, biscuits, doughnuts) :

11) In the years before your MS symptoms began did you frequently have any of the following problems?

a) Pain or pressure in the stomach or intestines
b) Excessive gas
c) Diarrhea
d) Constipation

Specify frequency and severity:

11a) List any foods you are allergic to.

12)Before your symtoms started did you frequently have cold hands or feet while others around you were warm?

a) Yes
a) No

Environmental

13) Based on your occupation or lifestyle do you think you have had greater than average exposure to any of the following?

a) Mercury
b) Lead

c)Other (specify): (Do not hit return)

d) Did you have any silver dental fillings any time before your symptoms began?

a) Yes
a) No

e) If for any reason you had all of your silver dental fillings removed, did your symptoms become:

a) Better
a) Worse
a) No different

f) Have you ever lived within 200 yards of high tension overhead electric wires?

a) Yes
a) NO

f1) If yes, how many years? (Do not hit return)

h) Have you ever lived within 2 miles of a nuclear power plant?

a) Yes
a) No
h1) If yes how many years? (Do not hit return)

If you don't have MS skip to question 15.
14) Some people recover from MS. If you believe you have recovered please answer the following questions.

Check whichever applies:

14a) Progress of disease has stopped but symptoms persist

14b)How many months since the disease stopped? (Do not hit return)

14c) Symptoms are mostly gone
14d)How many months since the symptoms disappeared? (Do not hit return)

14e) If you believe you have recovered from MS, what do you attribute your recovery to?

a) Diet
b) Diet supplements
b) Exercise
b) Lifestyle
b) Prayer
b) Luck

Please describe (Do not hit return)

15) Please list the cities that you have lived in or nearest to and the approximate years that you lived there. (Approximate locations within 100 miles are OK). If you know the latitude of that city please list that also.

Years

From   TO  City         State       Country       Latitude

Thank you for taking the MS survey

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